Determinanten der Shuntoffenheit - Der Dialyseshunt...8. Symposium Dialyseshuntchirurgie...

8. Symposium DialyseshuntchirurgieFortbildungsveranstaltung der IAD, Hotel Elephant, Weimar 11.12.2015

D. Döbrich, Th. Röder, Y. Al-Shargabi

Determinanten der Shuntoffenheit

HELIOS Klinik Blankenhain

HELIOS Klinik BlankenhainDeterminanten der Shuntoffenheit | D. Döbrich, Th. Röder, Y. Al-Shargabi | Weimar | 11.12.2015 2


Einflussfaktoren der Shuntoffenheit

Determinanten der Shuntoffenheit | D. Döbrich, Th. Röder, Y. Al-Shargabi | Weimar | 11.12.2015

AlterGeschlechtBody Mass IndexHerzinsuffizienzAntikoagulanzienAndere Medikamente (z. B. Ca++-Kanal Blocker, Statine)

Vaskuläre Risikofaktoren

Arterielle Hypertonie

Hyperlipidämie

Diabetes mellitus

Nikotinabusus

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Winkelmayer, Wolfgang C., "Tackling the Achilles' Heel of Hemodialysis," New England Journal of Medicine, 2011, 372 - 374.Smith, George E., Gohil, Risha und Chetter, Ian C., "Factors affecting the patency of arteriovenous fistulas for dialysis access," Journal of Vascular Surgery, 2012, 849 - 855.Puskar, Damir, Pasini, Josip, Savic, Ivan, Bedalov, Goran und Sonicki, Zdenko, "Survival of primary arteriovenous fistula in 463 patients on chronic hemodialysis," Croatian medical journal, 2002, 306-11.Monroy-Cuadros M, Yilmaz S, Salazar-Bañuelos A, Doig C. Risk Factors Associated with Patency Loss of Hemodialysis Vascular Access within 6 Months. Clinical Journal of the American Society of Nephrology : CJASN. 2009; 5:1787 - 1792


Einflussfaktoren der Shuntoffenheit


Gefäßparameter

Durchmesser

Arterial Resistance Index

Venous Distensibility

Shuntart

Operateur / OP-Technik

Anastomosenart

Präoperativer Ultraschall

Postoperative Flussmessung

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Winkelmayer, Wolfgang C., "Tackling the Achilles' Heel of Hemodialysis," New England Journal of Medicine, 2011, 372 - 374.Smith, George E., Gohil, Risha und Chetter, Ian C., "Factors affecting the patency of arteriovenous fistulas for dialysis access," Journal of Vascular Surgery, 2012, 849 - 855.Puskar, Damir, Pasini, Josip, Savic, Ivan, Bedalov, Goran und Sonicki, Zdenko, "Survival of primary arteriovenous fistula in 463 patients on chronic hemodialysis," Croatian medicaljournal, 2002, 306-11.Monroy-Cuadros M, Yilmaz S, Salazar-Bañuelos A, Doig C. Risk Factors Associated with Patency Loss of Hemodialysis Vascular Access within 6 Months. Clinical Journal of the American Society of Nephrology : CJASN. 2009; 5:1787 - 1792


Eigene Patienten


Erstanlagen

Radiocephale Shunts

Terminale Niereninsuffizienz

n = 133

Primäre Shuntoffenheit

„Zeitintervall von der Shuntanlage bis zu jeder ersten Intervention/Operation um die Shuntfunktion zu erhalten oder zu verbessern“

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Sidawy AN, Gray Richard Besarab A, Henry Mitchell Ascher E et al. Recommended standards for reports dealing with arteriovenous hemodialysis accesses. Journal ofVascular Surgery. 2002; 35:603 - 610.


Demographische Daten

Determinanten der Shuntoffenheit | D. Döbrich, Th. Röder, Y. Al-Shargabi | Weimar | 11.12.2015 6

Geschlechtsverteilung Altersverteilungn = 133


Body Mass Index


https://en.wikipedia.org/wiki/Body_mass_index#/media/File:Body_mass_index_chart.svg


Comorbiditäten


56% 56% 96% 30%


Comorbiditäten


Herzinsuffizienz Diabetes mellitus


Alter


EinflussShuntreifung Shuntoffenheit Quelle

Ø Olsha, Oded, Hijazi, Jamal, Goldin, Ilya und Shemesh, David, "Vascular access in hemodialysis patients older than 80 years," Journal of Vascular Surgery, 2015, 177 - 183.

Ø Lauvao, Lannery S., Ihnat, Daniel M., Goshima, Kaoru R. et al., "Vein diameter is the majorpredictor of fistula maturation," Journal of Vascular Surgery, 2009, 1499 - 1504.

Ø Swindlehurst, Nicola, Swindlehurst, Andrew, Lumgair, Heather et al., "Vascular access forhemodialysis in the elderly," Journal of Vascular Surgery, 2011, 1039 – 1043

+Tordoir, J. H. M., Bode, A. S. und van Loon, M. M., "Preferred Strategy for HemodialysisAccess Creation in Elderly Patients," European Journal of Vascular and EndovascularSurgery, 2015, 738 - 743.

+Monroy-Cuadros M, Yilmaz S, Salazar-Bañuelos A, Doig C. Risk Factors Associated with Patency Loss of Hemodialysis Vascular Access within 6 Months. Clinical Journal of the American Society of Nephrology : CJASN. 2009; 5:1787 - 1792.

ØAllon, Michael, Litovsky, Silvio, Young, Carlton J. et al., "Medial fibrosis, vascularcalcification, intimal hyperplasia, and arteriovenous fistula maturation," American journal ofkidney diseases : the official journal of the National Kidney Foundation, 2011, 437-43


Alter


LogRank-Test (5%)


Geschlecht



Ø Lauvao, Lannery S., Ihnat, Daniel M., Goshima, Kaoru R. et al., "Vein diameter is themajor predictor of fistula maturation," Journal of Vascular Surgery, 2009, 1499 - 1504.

+Bashar, Khalid, Zafar, Adeel, Elsheikh, Sawsan et al., "Predictive parameters ofarteriovenous fistula functional maturation in a population of patients with end-stage renal disease," PloS one, 2015, e0119958.


Geschlecht


keine Herzinsuffizienz (nw= 37, nm= 56)

LogRank-Test (10%)


Diabetes mellitus Typ II




+Conte, Michael S., Nugent, Helen M., Gaccione, Peter, Roy-Chaudhury, Prabir und Lawson, Jeffrey H., "Influence of diabetes and perivascular allogeneic endothelial cellimplants on arteriovenous fistula remodeling," Journal of vascular surgery, 2011, 1383-9.

ØSedlacek, M., Teodorescu, V., Falk, A., Vassalotti, J. A. und Uribarri, J., "Hemodialysisaccess placement with preoperative noninvasive vascular mapping: comparison betweenpatients with and without diabetes," American journal of kidney diseases : the officialjournal of the National Kidney Foundation, 2001, 560-4.

ØAllon, Michael, Litovsky, Silvio, Young, Carlton J. et al., "Medial fibrosis, vascularcalcification, intimal hyperplasia, and arteriovenous fistula maturation," American journalof kidney diseases : the official journal of the National Kidney Foundation, 2011, 437-43.

+Monroy-Cuadros M, Yilmaz S, Salazar-Bañuelos A, Doig C. Risk Factors Associated with Patency Loss of Hemodialysis Vascular Access within 6 Months. Clinical Journal of the American Society of Nephrology : CJASN. 2009; 5:1787 - 1792.


Diabetes mellitus Typ II


LogRank-Test (9%)


Body Mass Index



+Evans, Richard P. T., Meecham, Lewis, Buxton, Pauline et al., "Vascular access in theobese: superficialisation of native radio-cephalic and brachio-cephalic fistulae," The journal of vascular access, 2015, 126-9.

+Kim, Jwa-Kyung, Jeong, Jae Han, Song, Young Rim et al., "Obesity-related decrease in intraoperative blood flow is associated with maturation failure of radiocephalicarteriovenous fistula," Journal of vascular surgery, 2015, 1010-1017.e1.



Body Mass Index


LogRank-Test (41%)


Hyperlipidämie



+De Marchi, S., Falleti, E., Giacomello, R. et al., "Risk factors for vascular disease andarteriovenous fistula dysfunction in hemodialysis patients," Journal of the American Society of Nephrology : JASN, 1996, 1169-77.



Hyperlipidämie


LogRank-Test (78%)


Arterielle Hypertonie


Die Variabilität des systolischen Blutdrucks korreliert signifikant mit dem Risiko einer Shuntdysfunktion. Mutmaßlich erhöht der hohe systolische Blutdruck die Entzündungsaktivität in der Venenwand.Cheng, Yue, Zhang, Fan, Zhu, Jun et al., "Influence of blood pressure variability on the life of arteriovenous fistulae in maintenance hemodialysispatients," Clinical hemorheology and microcirculation, 2015,.

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Herzinsuffizienz


Die Wahrscheinlichkeit, die Dialyse mit einem suffizienten Shunt zu beginnen ist bei Patienten mit Herzinsuffizienz 34% niedriger.Lilly, Michael P., Lynch, Janet R., Wish, Jay B. et al., "Prevalence of arteriovenous fistulas in incident hemodialysis patients: correlation with patient factors that may be associated with maturation failure," American journal of kidney diseases : the official journal of the National Kidney Foundation, 2012, 541-9.

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Herzinsuffizienz


LogRank-Test (20%)


Durchmesser Arterie


Der Mindestdurchmesser der A. radialis für eine optimale Shuntreifung und lange primäre Offenheit ist 2 mm.Kordzadeh, Ali, Chung, Jameson und Panayiotopoulos, Yiannis P., "Cephalic vein and radial artery diameter in formation of radiocephalic arteriovenousfistula: a systematic review," The journal of vascular access, 2015, 506-11.

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Durchmesser Arterie


LogRank-Test (28%)


Keine Herzinsuffizienz

Herzinsuffizienz und arterieller Gefäßdurchmesser


LogRank-Test (87%)


NYHA III-IV

Herzinsuffizienz und arterieller Gefäßdurchmesser


LogRank-Test (1%)


Durchmesser Vene



+Kordzadeh, Ali, Chung, Jameson und Panayiotopoulos, Yiannis P., "Cephalic vein andradial artery diameter in formation of radiocephalic arteriovenous fistula: a systematicreview," The journal of vascular access, 2015, 506-11.

+ Lauvao, Lannery S., Ihnat, Daniel M., Goshima, Kaoru R. et al., "Vein diameter is themajor predictor of fistula maturation," Journal of Vascular Surgery, 2009, 1499 - 1504.

+ +Dageforde, Leigh Anne, Harms, Kelly A., Feurer, Irene D. und Shaffer, David, "Increasedminimum vein diameter on preoperative mapping with duplex ultrasound is associatedwith arteriovenous fistula maturation and secondary patency," Journal of VascularSurgery, 2015, 170 - 176.


Durchmesser Vene


LogRank-Test (13%)



Herzinsuffizienz und venöser Gefäßdurchmesser


LogRank-Test (59%)


Herzinsuffizienz NYHA III / IV

Herzinsuffizienz und venöser Gefäßdurchmesser


LogRank-Test (6%)


Thrombozytenaggregationshemmer



Ø +Jackson, Andrew J., Coats, Paul und Kingsmore, David B., "Pharmacotherapy to improveoutcomes in vascular access surgery: a review of current treatment strategies," Nephrology Dialysis Transplantation, 2012, 2005 - 2016.

Ø +Dember, Laura M., Beck, Gerald J., Allon, Michael et al., "Effect of clopidogrel on earlyfailure of arteriovenous fistulas for hemodialysis: a randomized controlled trial," JAMA, 2008, 2164-71.

Ø +Palmer, Suetonia C., Di Micco, Lucia, Razavian, Mona et al., "Antiplatelet Therapy toPrevent Hemodialysis Vascular Access Failure: Systematic Review and Meta-analysis," American Journal of Kidney Diseases, 2013, 112 - 122.





LogRank-Test (59%)


Herzinsuffizienz NYHA III-IV



LogRank-Test (20%)


Fazit


• Bei Patienten mit einer relevanten Herzinsuffizienz keine Shuntanlagen mit grenzwertig kleinen Gefäßen

• Die bestmögliche Behandlung der kardiovasculär relevanten Begleiterkrankungen dient auch der Shuntoffenheit.

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Vielen Dank!Dr. med. Dinah DöbrichHELIOS Klinik Blankenhainwww.helios-kliniken.de

Für Fragen und Hinweise stehe ich in der Diskussion sowie danach gerne zur Verfügung, auch via

[email protected]

Determinanten der Shuntoffenheit - Der Dialyseshunt...8. Symposium Dialyseshuntchirurgie...

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